What is the recommended treatment for an ingrown toenail?

Ingrown Toenail Treatment

For mild ingrown toenails, start with conservative management including twice-daily antiseptic soaks for 10-15 minutes followed immediately by mid- to high-potency topical corticosteroid ointment to the nail fold, combined with mechanical relief techniques such as cotton wisp insertion or gutter splinting; if no improvement occurs after 2-4 weeks or if moderate-to-severe disease is present, proceed to surgical intervention with partial nail avulsion plus phenolization, which is the most effective approach for preventing recurrence. 1, 2, 3

Initial Assessment and Conservative Management

First-Line Conservative Approach (Mild Cases)

• Perform antiseptic soaks twice daily for 10-15 minutes using either dilute vinegar (50:50 dilution) or 2% povidone-iodine solution 1, 2
• Apply mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily immediately after soaking to reduce inflammation 1, 2
• Implement mechanical separation techniques:
  • Insert cotton wisps or dental floss under the ingrown lateral nail edge to lift the nail away from the inflamed tissue 2, 4
  • Consider gutter splinting using a plastic tube with a lengthwise incision placed on the lateral nail edge 2, 4
  • Tape the lateral nail fold away from the nail plate 2

When to Add Antibiotics

• Do not routinely prescribe antibiotics unless clear signs of infection are present, such as purulent drainage or localized cellulitis with significant erythema extending beyond the nail fold 2
• When antibiotics are indicated, target Staphylococcus aureus and gram-positive organisms 2
• For recurrent, severe, or treatment-refractory cases, use doxycycline 100 mg twice daily with follow-up after one month 2

Footwear and Nail Care Modifications

• Correct inappropriate footwear by wearing comfortable, well-fitting shoes with adequate toe box space to reduce pressure 1, 4
• Trim toenails straight across (not too short and not rounded at corners) to prevent recurrence 1, 2
• Manage contributing factors such as hyperhidrosis and onychomycosis if present 1, 4

Surgical Management

Indications for Surgery

• Reassess after 2 weeks of conservative management 2
• Escalate to surgical consultation if persistent pain or drainage continues beyond 2-4 weeks despite appropriate conservative therapy 2
• Proceed to surgery if granulation tissue develops 2
• Consider surgery for moderate-to-severe cases at initial presentation 4

Surgical Technique

• Partial nail avulsion combined with phenolization is the most effective surgical approach for preventing symptomatic recurrence compared to surgical excision without phenolization 3
• Partial nail avulsion followed by either phenolization or direct surgical excision of the nail matrix are equally effective treatment options 3
• Alternative surgical approaches include complete nail excision, electrocautery, radiofrequency ablation, or carbon dioxide laser ablation of the nail matrix 3, 5

Important Surgical Caveat

• Partial nail avulsion with phenolization has a slightly increased risk of postoperative infection compared to surgical excision alone, but this is outweighed by superior recurrence prevention 3
• Oral antibiotics before or after phenolization do not improve outcomes 3

Post-Procedure Care

• Continue antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 1
• Apply mid- to high-potency topical steroid ointment to nail folds twice daily 1
• Avoid trauma to the affected digit and wear protective gloves during activities involving water exposure or chemicals 1

Prevention of Recurrence

• Educate patients on proper nail care: trim nails straight across and avoid rounding the corners 1, 2
• Wear appropriate footwear that accommodates the shape of the feet and fits properly 1, 2
• Apply topical emollients daily to cuticles and periungual tissues to maintain skin barrier function 1, 2
• Avoid manipulating cuticles or using nails as tools 2

Special Considerations for Diabetic Patients

• Diabetic patients require more aggressive monitoring and prompt treatment by trained healthcare professionals, as ingrown toenails can progress to foot ulceration with significant morbidity 1, 2
• Provide integrated foot care every 1-3 months for diabetic patients 2
• For non-rigid hammertoes with nail changes in diabetic patients, consider digital flexor tendon tenotomy or orthotic interventions to reduce excess callus and prevent ulceration 1

Common Pitfalls to Avoid

• Do not round the corners when trimming toenails, as this increases recurrence risk 1, 2
• Avoid prescribing antibiotics routinely without clear signs of infection 2
• Do not delay surgical referral beyond 2-4 weeks if conservative management fails 2
• In diabetic patients, do not underestimate the risk of progression to foot ulceration 1, 2